GLASGOW, SCOTLAND — Because the presenting symptoms of systemic lupus erythematosus are manifold, may mimic other disorders, and can evolve over time, assembling the diagnostic puzzle sometimes requires digging into the patient's past, according to Dr. Hala Y. Sadik.
This is particularly the case when the onset is acute, as happened in a case seen by Dr. Sadik of the University of Liverpool Academic Rheumatology Unit, University Hospital Aintree, Liverpool, England.
In August 2005, a 57-year-old woman presented with hypothermia, bradycardia, confusion, a low score on the Glasgow coma scale, and hyponatremia. Plasma sodium was low, at 120 mmol/L; plasma osmolality was low, at 235 mosmol/kg; and urinary sodium and osmolality were high. The diagnosis of syndrome of inappropriate antidiuretic hormone secretion was made, Dr. Sadik wrote in a poster session at the annual meeting of the British Society for Rheumatology. Initial management included fluid restriction and administration of double-strength normal saline, which normalized the plasma sodium level.
Initial MRI of the head raised the possibility of neurosarcoidosis, but serum angiotensin-converting enzyme levels and chest x-ray were normal.
A repeat MRI with gadolinium suggested demyelinating disease or systemic lupus erythematosus. Immunology profile findings included positive antinuclear antibody (ANA) and double-stranded DNA antibody. Thrombocytopenia and lymphopenia also were present.
At this point, her previous case records were located at another hospital. These revealed that she had been admitted in 1992 with a 2-week history of arthralgias, Raynaud's phenomenon, thrombocytopenia, lymphopenia, and positive ANA.
A diagnosis of lupus had been considered at that time, and she was followed for several years as an outpatient, but ANA remained weakly positive and double-stranded DNA was persistently negative, so the diagnosis had been dismissed, Dr. Sadik wrote.
With improvements on the Glasgow coma scale during her current admission, it became apparent that the patient was profoundly depressed, so she was treated with mirtazapine. Following a diagnosis of neuropsychiatric lupus, she began treatment with intravenous methylprednisolone and cyclophosphamide.
Significant improvements were seen in her disabling depression, and her hematologic parameters normalized, according to Dr. Sadik.
This case highlights the necessity for careful review of medical history and investigation results in any case where acute nonspecific symptoms might represent neuropsychiatric lupus, she said.